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VERIFICATION OF VEHICLE COMMISSZARY <br /> Please provide all information requested. An ir1complete appiicatian mai,delay approval.. <br /> VEHICLE INFORMAT[ON <br /> Vehicle N2me (DBA): <br /> Address for Vehicie: —7- <br /> Strut Address GES° <br /> 5) License Plate#: 4) Year: %o 0_5 <br /> 2) Vehicle Vin#: l.CI�S'c�4�/S`~T3S57���) lcfakeilodeE: Z% <br /> 3) State Decal #: 6) Color: J`i/`� <br /> Name: /V7�J, �l _ <br /> Address of Owner: /�3 1 S, <' `1�I <br /> strut address 1iiCy <br /> — -- <br /> I he mobile iVVu aGilii"Jiialt v"°"'atG v°tet E%g=="��'fcsary 3rF�'shall CepQrt to the GarTirntSsar�°at IeaS.t ante each �. <br /> y ��° <br /> operating day for cleaning and servicing (CalCode sections 114-295 & 1'14-247). It the use of the commissary is <br /> discontinued, the per it holder must notify this office to make the necessary changes. FaRure to €eofi`y this <br /> of Ce ay result in p mit rev cation and penalties. / <br /> Si lure of Vehicle O erat61 Dare <br /> GOOMISSARY INFORMIAT, <br /> Business blame: zz r 2 � <br /> _ 7 <br /> Owner Name: `� / U <br /> Site address: <br /> �t rEs city <br /> I Phone: (7V `� 4 /> r,62 Z <br /> i,the commissary owner, can and will provide the necessary`fac:l:ties for the above mentioned vel�FCle at€LSV <br /> commissary as checked below: <br /> ,2 tensil washing sink F1 �Store frozen food chicle wash fs�lities <br /> C�'Liquid&solid waste disposal (2 or 3 compartments) <br /> reparation of food [2,bt6f_&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> Sr-edry food/supplies rovide potable water vernight parking dequate electrics outlets <br /> Signature of Commissa Owner/Operator Date <br /> HEATH DEPARTMENT f <br /> If the commissary/food establishment is outside san Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Corr"�missarylfood establishment is in <br /> I <br /> County. <br /> I <br /> l Signature of County RENS Date <br /> 5 of 6 MFPU APPLICATION <br /> EHD 16-017 <br /> 7118/2008 <br />